Provider Demographics
NPI:1194826578
Name:UDZIELA, ANTHONY DALE (PHD)
Entity Type:Individual
Prefix:MR
First Name:ANTHONY
Middle Name:DALE
Last Name:UDZIELA
Suffix:
Gender:M
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13354 MANCHESTER RD
Mailing Address - Street 2:STE 220
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63131-1709
Mailing Address - Country:US
Mailing Address - Phone:314-614-9730
Mailing Address - Fax:314-692-7929
Practice Address - Street 1:13354 MANCHESTER RD
Practice Address - Street 2:STE 220
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63131-1709
Practice Address - Country:US
Practice Address - Phone:314-614-9730
Practice Address - Fax:314-692-7929
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOPY01064103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
118890OtherHEALTHLINK
061234OtherEXCLUSIVE CHOICE
MO26999OtherBLUE CROSS BLUE SHIELD OF
00007511UDZOtherMERCY HEALTH PLAN
132604OtherCMR
6153019OtherUNITED HEALTHCARE UNITED
A805509OtherVALUEOPTIONS